Chat Event Transcript: Mood Disorders and Epilepsy with Dr. John Barry

This event took place on May 13, 2003

Posted: June 17, 2003

Does epilepsy impact your mood? Or could depression or anxiety be a side effect of the epilepsy meds?

Our guest, John Barry, M.D., is an assistant professor of Psychiatry and Neurology at Stanford University Medical Center. He presently runs the neuropsychiatry clinic and the individual psychotherapy clinic for the residents. His main interest is in the interface between neurology and psychiatry especially related to people with epilepsy.

Admin Hello and welcome to tonight's event. Our guest is John Barry, M.D., assistant professor of Psychiatry and Neurology at Stanford University Medical Center. He presently runs the neuropsychiatry clinic and the individual psychotherapy clinic for the residents. His main interest is in the interface between neurology and psychiatry especially related to people with epilepsy. This evening, we're taking live questions as well as those that have been submitted in advance from our users.

Dr. Barry: One of the things we'll be talking a lot about today is depression and anxiety in people with epilepsy. Many questions come up about whether depression and epilepsy is more frequent than is seen in other chronic illnesses -- and it seems as though depression in many neurological illnesses are more frequently seen in people with epilepsy than what would be expected in the general population.

In a recent survey of almost 700 people with epilepsy, it was found that nearly 25 percent met criteria for a significant depressive disorder.

When we talk about depression, it's important to define terms -- people with a significant depression have symptoms that include decreased ability to sleep, loss of interest or joy in life, irritability and anxiousness ... and I should stop there and note that irritability is something noted frequently in people with epilepsy. People experiencing depression may have a decrease in energy and concentration ability and sometimes thoughts of life not being worth living.

Some of the symptoms I've just listed can be side effects of antiepileptic drugs. One good rule of thumb is that if the symptoms noted previously come on associated with the start of a new AED, then the possibility of there being a significant association is an important one.

It would be wise, at that point, to notify the treating physician so that this important side effect can be investigated further. One important message is that depression seen in people with epilepsy can be treated effectively. Hopefully, as we go through some of the questions tonight, we'll demonstrate how I approach the evaluation of depression in people with epilepsy.

Another important psychiatric problem that is seen even more frequently than depression is anxiety. In one study that we're just recently completing, almost half of the people with epilepsy that we evaluated had significant complaints and met the criteria for anxiety disorders. Anxiety, when it's associated with depression, can be particularly disabling and needs treatment.

Mike: Should depression and anxiety in persons with epilepsy be treated any differently from the same conditions experienced by others who don't have epilepsy? Who should be expected to treat the depression experienced by persons with epilepsy? My neurologist would be more apt to consider the effects of antidepressant treatments on my seizures. But a psychiatrist would probably make a more accurate diagnosis and may know of the most effective treatment for my depression.
Dr. Barry: There are some important considerations when treating people with epilepsy who have complaints of depression or anxiety. Many of the medications that we use on patients who have psychiatric problems that don't seem to be associated with a medical condition but there are some that we probably should avoid.

One of the concerns that are often times voiced by people who treat persons with epilepsy is that the antidepressants decrease the seizure threshold. In other words, they increase the possibility of a person having a seizure. Because of that, antidepressants in general, are avoided.

This is a serious mistake, since people with epilepsy can use antidepressants very safely. The Seratonin Reuptake Inhibitors (SSRI) -- those that belong in the family of Prozac -- can be used safely. One must always watch for an increase in seizure frequency, but generally, if the dose is started low and gradually increased, these medications are safe and extremely effective.

Anxiety can also be treated with the same medications -- the SSRI's.

The question comes up about who should start treatment. Many neurologists feel very comfortable treating depression and starting antidepressants. My usual recommendation is that if the neurologist feels uncomfortable, then the patient should be referred. If, after a trial of one or two antidepressants, symptoms remain, then a referral would be indicated. In addition, if there are severe symptoms of depression (i.e. suicidal ideation) and/or psychotic symptoms, then the person should be referred, probably for inpatient treatment, and also to a psychiatrist.

Debbie: Is the criteria for differential diagnosis for depression the same for individuals with epilepsy? What is the preferred treatment? Success?
Dr. Barry: There is a significant overlap between the symptoms of depression as manifest in patients with depression not related to medical causes and symptoms of depression in people who have epilepsy.

There are several authors who have had a great deal of experience treating people with epilepsy who have noted possibly unique presentations of depression in people with epilepsy. The diagnosis for a major depressive disorder using standardized criteria requires that the depression be persistent for at least two weeks.

It has been noted by these authors that depression in people with epilepsy fluctuates -- it may be disabling, but if often times can come and go. Whether this is a unique feature of depression in people with epilepsy or not requires further investigation. However, it does seem to be a consistent observation by many authors.

It has also been noted by the same authors that these symptoms can be treated very effectively with antidepressants.

Another aspect that's very important when I approach the evaluation of a person with epilepsy who has symptoms of depression, is to note the appearance and association of those symptoms in conjunction with the patient's seizures themselves. It is not infrequent for people with epilepsy to have mood changes that are seen before, during and after a seizure.

People with epilepsy who are depressed can have their symptoms of depression increased around the time of their seizure. Especially post-ictally -- after the seizure itself. Some people with epilepsy only have their depression after a seizure -- this can persist for two to three or more days.

The treatment of this type of an event would be to maximize treatment for the seizure disorder itself.

Mighty: I just had major surgery in February. I was operated on my left temporal lobe due to my epilepsy. I am thankful that I am not having seizures anymore but I am now suffering from depression. Could you please tell me how long this will last.
Dr. Barry: Temporal lobectomy is an extremely effective treatment for localization-related epilepsy situated in the temporal lobe. Depression after a temporal lobectomy is not uncommon.

It often times happens in the first four to six months after surgery. Temporal lobectomies, because of their effectiveness, may paradoxically cause this problem. What I mean by this is that by very acutely resolving the patient's seizure disorder, it can present the individual with very unique adjustment problems. Even though this may not seem to make any sense, I frequently warn people before the surgery that the adjustments to not having a seizure can be significant.

Epilepsy surgery is one of the unique interventions in medicine that can be so effective so quickly. People who have had chronic seizures adjust to their seizure disorder but it often times prevents them from mastering many of the maturational tasks that we all face without seizures.

People are therefore presented with the daunting task of adjusting to not having seizures without having the time that most of us have to master maturational tasks. All of a sudden, people expect and the patients who undergo the surgery expect as well, that they will be able to do things "like everybody else."

But because of their seizures, things that they avoided in the past, they are all of a sudden expected to do with proficiency. This may include work activities and interpersonal relationship issues -- these are tasks that most of us take years to develop confidence in.

After surgery, expectations are high and adjustment time is short.

I recommend that a therapist be available for both the family as well as the patient having a temporal lobectomy to help adjust to the changes.

CarolG: I have a reverse question. Does being depressed or anxious about something in your life affect seizure activity aside from them being possible side effects of medication?
Dr. Barry: Carol brings up a very interesting question that it's important to pay some attention to ... Can depression actually make seizures worse?

In several studies, depression has actually been seen before the onset of a seizure disorder. In addition, treating depression in people with epilepsy has been noted in several studies to be associated with a decrease in seizure frequency.

Louise: How do you explain to an employer that you are NOT "trying" to be moody? I lost my job as a first grade teacher because my school district said other teachers were complaining about me being too quiet, sometimes upset, and somewhat withdrawn. This is very strange, I know, but it really happened and it made my depression and anxiety even worse. It has been very difficult to stabilize my meds and I also wondered if that was common.
Dr. Barry: I think this is a difficult issue, explaining to people about a mood disorder associated with epilepsy.

Unfortunately, depression is often times not brought up by people with epilepsy to their physician because of a fear of a double stigma. In other words, it's bad enough to have epilepsy ... but it's even worse to have depression associated with it.

What I would suggest -- and I am not pollyannish enough to expect it work in every situation -- explaining what your experiencing and the difficulties to an employer can often times be very helpful.

Certainly, it is my hope and those of all of us who work with people with epilepsy and depression that people will understand that these are physical diseases with physical causes, and not something that you "choose" to have. Just as you would expect your employer to be responsive to an obvious physical ailment like a broken leg, I would hope that they would also be responsive to the fact that your epilepsy is difficult to control and that you're also having problems with depression as well.

Kate: I am taking depakote and klonipin for my seizures. I've been depressed and have tried a few prescription anti-depressants. They make me feel grouchier. Would the herbal medications such as St. Johns Wort or SamE interact with the meds I'm taking? Do you think these herbal meds are helpful? Thank you.
Dr. Barry: The first issue that we should consider is whether they work. The herb that most frequently used for depression is St. John's Wort... and at least to my knowledge, it's unclear how effective this medication is compared to standard interventions.

Studies have conflicted so far.

My second concern is whether they interfere with the medications that you're using for epilepsy the side effects of St. John's Wort appear to be low. However, there is a possibility of it interacting with phenytoin, carbanazepine, and phenobarbital.

Another concern is -- can this medication make seizures worse. Any herbal treatment that contains ephedrine and/or caffeine can worsen seizure control. Although there have been no formal studies that I know of, ginko and ginseng may also increase the risk of seizures.

It's important to remember that natural compounds are still drugs that need to be treated and investigated as such. My overall statement about herbs is to be careful -- I recommend the standard treatments.

Debbie: What if anything is being done to encourage mental health providers to take an interest helping those with epilepsy?
Dr. Barry: I think this is an excellent question and I wish I had a good answer -- it's certainly something that we're working on very actively within the Epilepsy Foundation.

I think that there is a reluctance for a psychiatrist to treat people with epilepsy because of the unknown. I hope that as we educate both neurologists about the frequency of depression and anxiety disorders in people with epilepsy, that the frequency of poor recognition, diagnosis and treatment of these disorders in epilepsy clinics will decrease.

Conversely, I also hope that educating psychiatrists about the issues that face people who have a diagnosis of epilepsy, that'll make it easier for them to feel comfortable treating patients with epilepsy and depression or anxiety.

I also hope that by emphasizing the fact that people with epilepsy and a psychiatric disorder can be treated effectively and safely, that this will increase comfort of psychiatrists in treating patients with epilepsy.

Suze: Are depression or bipolar related in anyway to epilepsy? If so, is it possible that they are a side effect of my meds? (neurontin & zonegran)
Dr. Barry: We've talked about depression at length tonight, but we haven't talked about bipolar disorder.

It used to be thought that bipolar disorder was infrequent in people with epilepsy. However, this may not be true. There was a recent study that was presented at a neurology meeting that noted the frequency of bipolar disorder in people with epilepsy at a significantly higher rate than that seen in those with asthma, diabetes or the general population.

Another question that was also asked here is association with medication. One of the drugs that was asked about here was zonegran or zonisamide. Mania has been associated with that medication.

Again, the rule of thumb that we discussed before is operative here as well. In other words, if there's a new onset of a psychiatric disorder associated with the start of a new antiepileptic drug, the possibility of this medication causing the psychological problem needs to be investigated.

suzy: What effects do hormonal changes have on epilepsy and depression?
Dr. Barry: This is again, another good question ...

Hormone changes can be very important in affecting seizure frequency fluctuations in hormone levels, during the menstrual cycle, for example, may affect seizure threshold and mood. It has been estimated that up to 70 percent of women notice some changes in seizure frequency associated with ovulation and menstruation.

This has been termed "catamenial" epilepsy.

Pre-menstrual dysphoric disorder is a term used to describe depression seen associated with menstruation. Interesting enough, antidepressants can be very useful for PMDD.

So there does seem to be a significant interplay between depression, mood and seizures.

Admin: Well, Dr. Barry ... it's certainly been a pleasure having you by today. Do you have any closing thoughts for us?
Dr. Barry: It is also important to recognize the infrequency with which these disorders are diagnosed in epilepsy clinics. For example, in one particular study, depressed people with epilepsy, 43 percent of people with a major depressive disorder and 68 percent with a minor depressive disorder were untreated. In addition, 38 percent of people with a history of lifetime episodes of major depression, had never received therapy for depression. In a study of 44 children with epilepsy, 26 percent were found to have a significant depressive disorder and none of the children had been diagnosed with or treated for depression. In addition to that, suicide in people with epilepsy is higher than that seen in the general population. Clearly, we have a lot of work to do -- in both recognition and treatment. It's imperative that we get the word out, not only to neurologists, but psychiatrists and to the general populace as well. These are disorders that can be treated and we should continue to educate to decrease the stigma of epilepsy and mood disorders. Thank you all for your time tonight -- a transcript of this entire event will be posted shortly.